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PHS/SAl..AOUI4 COUNTY - ENVIRONMENTAL HEALTH DIVISI( <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> J <br /> UPDATE: / �1 ,(; BY: :�� REVIEWED 8Y: �� DATE ENTERED: /,)/ BY: <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT COMP # LOC CODE / DIST # <br /> LOT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT - <br /> OTHER CONTACT RWOCS CONTACT WOR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT OW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> E�NNFORRCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME �/Y Q 141, �. <br /> ADDRESS <br /> CITY .� STATE -� 21P <br /> CONTACT NAME _. P"E: <br /> PROPERTY OWNER �'W, .2-49 <br /> COMPANY NAME i PHONE <br /> CONTACT NAME} PHONE <br /> i ADDRESS <br /> i <br /> CITY Lbd i <br /> STATE - � 2IP D <br /> #ESPONSIBL PARTY (If different werty Owner) <br /> / <br /> COMPA NAME �._7 Al. y Y PHONE <br /> CONTACT NAME f 1 I PHONE <br /> ADDRESS I l li-# + D� '���, Y • <br /> CITY �� �.y1\_ STATE 2IP ) `� <br /> CONSULTANT PHONE <br /> UAR # ,, DATE PROP 65 # DATE <br /> STREET # '-/ (. `JI SITE STREET ` APN <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />